Pt also informs you he hasn’t be able to keep any food or water down due to nausea. Encourage oral fluid intake; administer IV fluids if necessary. Anesthesia 2. Nursing Dx: Hyperthermia related to the process of dengue virus infection. Liquids can help prevent dehydration. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. Infants are especially sensitive to over-bundling as they are unable to regulate temperature. Maximize heat loss and minimize external covering on clients body, keep clothing and bed linen dry, prevent the patient from getting draughts. It is recommended that, unless the child is visibly uncomfortable or in pain, fevers under 102° should not be treated. Obtain history from parent or caregiver to determine the cause. Pt’s skin turgor is greater than 5 seconds. Nursing Care Plan - NCP for Typhoid Fever. What’s beyond them? Fever The nurse is assessing a 7-year-old client for dehydration. Nursing interventions for dengue fever include • Eradication of mosquitoes by eliminating breeding places • restore blood volume • Deficient fluid volume related to an elevated body temperature should be monitered • Deficient fluid volume r/t increased metabolic state should be monitored. The nurse caring for a child admitted with gastroenteritis knows which of the following are signs of severe dehydration? This nursing care plan and diagnosis with nursing interventions is for the following conditions: Hyperthermia, Fever, High Temperature. Get baseline to determine if interventions are effective. 2. An 86 year old male comes into the ER. Nursing Care Plan for Rheumatic Heart Disease - Nanda Nursing Diagnosis for RHD Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. Alternatively, infants who are over bundled or in a very warm environment may develop a fever because the hypothalamus is not yet able to fully regulate temperature. Fever can cause fluid loss and dehydration, so drink water, juices or broth. Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. The most common way includes medications such as aspirin, acetaminophen and ibuprofen. How do you develop a nursing care plan? After 1 hour of appropriate nursing intervention the patient’s temperature will decrease to 37.5 o C. Long Term After 4 hours of appropriate nursing intervention the patient’s vital signs will return to normal range; with a temperature of 36.5-37.5 o C,pulse rate of 60-100bpm and respiratory rate of 12-20 cycles per min. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. Anticipate needing post-transfusion sample Physical exam.Begin with a careful review of all systems, and note the child’s physical condition; observe for any signs that may be classified as major o… Antibiotics – given to treat remaining strep infection, may be given orally or IM. We've taken what the science shows - image mnemonics work - but we've boosted the effectiveness by building and associating memorable characters, … -The nurse will have the patient rate his energy level on a scale 1-10 with 10 being the highest in energy within 72 hours of hospitalization. Primary goal is to effectively treat the infection and reduce symptoms. The nurse obtains vital signs. As the body temperature rises, the tissues use more water. 37.2 degrees will always be mild and should not be brought down not until it goes beyond 39.4 degrees which clearly indicates there is more than just the suspected illness. This course is going to expand on that for you and show you the most effective way to write a Nursing Care Plan and how to use Nursing Care Plans in the clinical setting. Vital signs: HR 100 regular, BP 135/78, Temperature 102.4 (orally), and O2 Saturation 95% on room air. umatic brain injury, they lack specificity in their recommendations for fever management, making it difficult to formulate appropriate protocols for care. The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. The following would be an example of a health promotion nursing intervention, which is an independent nursing action: Mrs. James has started a new medication for her high blood pressure. Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences. Lab results: WBC 19.3, UA (urinalysis) Leukocyte-esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative. Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Most physicians consider a fever to be a temperature over 100° when taken orally, 99° when taken under the arm and over 100.4° when taken rectally. If the child does not take in enough fluid when running a fever or with vomiting and diarrhea, they can dehydrate more quickly. Recite: Cover the note-taking column with a sheet of paper. Although thirsty, she is unable to tolerate fluids because of nausea and vomiting, and she has liquid stools 2–4 times per day. EVIDENCE “Clinical knowledge and understanding of the process of fever as an adaptive response has not resulted in changes to clinical guidelines or nursing interventions.” (Serase & Tranter, 2011, Thompson et al, 2011) A literature review based on improving evidence-based care for patients with fever consists of the following: “Actions involving administering antipyretics and tepid sponging Here are some factors that may be related to Hyperthermia: 1. Not all fevers need treatment. Anticonvulsants- given to treat involuntary movements (chorea) Nursing Interventions: -The nurse will assess every four hours the patient’s oral temperature and report any temperatures greater than 100.4 to the doctor.-The nurse will administer ordered antipyretics to the patient for a temperature greater than 100.4 per md order. Start intravenous therapy as prescribed. When the body temperature rises, it is because the hypothalamus is resetting the temperature in response to some illness or infection. What principle are they based on? You can try a number of things to make yourself or your child more comfortable during a fever: 1. 2. History.Obtain a complete up-to-date history from the child and the caregiver; ask about a recent sore throat or upper respiratory infection; find out when the symptoms began, the extent of the illness, and what if any treatment was obtained. Hyperthermia or commonly known as diagnosed is present when the body temperature is higher than 37á´¼C which can be measured orally.. NANDA Diagnosis of Hyperthermia for fever? Higher temperature makes it more difficult for germs that cause infection to live. Notify the patient's physician and blood bank. Nursing Care Plan for Typhoid Fever. Fevers can be mild and benign, but they can also alert to more serious diseases. The most important part of the care plan is the content, as that is the foundation on which you will base your care. Rest. Copyright © 2020 RegisteredNurseRN.com. Client will be able to report and show manifestations that fever is relieved or controlled through verbatim, temperature of 36.8á´¼C per axilla, respiratory rate of 12- 18 breaths per minute, pulse rate of 60- 75 beats per minute, stable blood pressure, absence of muscular rigidity/ chills and profuse diaphoresis after 4 hours of nursing care. If the child does not take in enough fluid when running a fever or with vomiting and diarrhea, they can dehydrate more quickly. NURSING CARE PLAN Deficient Fluid Volume ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES* Nursing Assessment Merlyn Chapman, a 27-year-old sales clerk, reports weakness, malaise, and flu-like symptoms for 3–4 days. fever nursing care plan - Scribd. The purpose of a fever is to help the body fight off infection. Not all fevers need treatment. All references to such names or trademarks not owned by NRSNG, LLC or TazKai, LLC are solely for identification purposes and not an indication of affiliation. After the Deficient Fluid Volume nursing diagnosis you can read Deficient Fluid Volume care plan. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus (straining on defecation), and borborygmi (hyperactive bowel sounds). Alternatively, infants who are over bundled or in a very warm environment may develop a fever because the hypothalamus is not yet able to fully regulate temperature. A 3-year-old child presents to the emergency department with lethargy. When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans. Pt is lethargic but alert enough to tell his health history and reason for coming to the ER. What are nursing care plans? Pt states he has became very weak the past week and is unable to walk to his mailbox because he is so tired. Pt also informs you he hasn’t be able to keep any food or water down due to nausea. By accessing any content on this site or its related media channels, you agree never to hold us liable for damages, harm, loss, or misinformation. Nursing Care Plans for Rheumatic Fever. Vigorous activity Select all that apply. 3. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words. Most physicians consider a fever to be a temperature over 100° when taken orally, 99° when taken under the arm and over 100.4° when taken rectally. If you do, you’ll retain a great deal for current use, as well as, for the exam. Children who have other diseases such as diabetes may experience excessive urination that results in dehydration. Dehydration 3. Not all fevers need treatment. Aspirin in children may cause Reye's syndrome, a sometime fatal illness. A child with an infection develops a fever. According to the daughter,  the patient lives alone and his wife passed away 6 months ago. Method for Mastering Nursing Pharmacology, 39 Things Every Nursing Student Needs Before Starting School. The body’s temperature is controlled by the hypothalamus in the brain. How do I write a Nursing Care Plan? Master Rheumatic Fever Interventions with Picmonic for Nursing RN With Picmonic, facts become pictures. Enter your email address below and hit "Submit" to receive free email updates and nursing tips. https://www.emedicinehealth.com/dehydration_in_children/article_em.htm#how_is_dehydration_in_children_diagnosed, https://www.healthline.com/health/parenting/signs-of-dehydration-in-toddlers#treatment, https://kidshealth.org/en/parents/fever.html, http://www.stanfordchildrens.org/en/topic/default?id=fever-in-children-90-P02512, That Time I Dropped Out of Nursing School. Inability to perspire 6. fever, malaise, headache, constipation or diarrhea, rose-colored spots on the chest, and enlarged spleen and liver. Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? We strive for 100% accuracy, but nursing procedures and state laws are constantly changing. Nursing Care Plan To Rehydrate The Patient. This can increase his or her risk for dehydration. Offer snacks and liquids frequently and monitor the patient’s response, especially with vomiting and diarrhea. Most children get enough water from eating and drinking, but the fluid loss in a child can be dangerous, leading to brain damage or even death. When the body temperature rises, it is because the hypothalamus is resetting the temperature in response to some illness or infection. Start studying Nursing interventions for clients with a fever or hypothermia. 1,2 Normal body temperature can fluctuate and average between 97.5°F (36.4°C) and 98.9°F (37.2°C). The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever. Children may be more responsive to frozen juice bars, ice pops, or flavored gelatin. Registered Nurse, Free Care Plans, Free NCLEX Review, Nurse Salary, and much more. Select all that apply. Determine fluid balance; monitor for and measure vomiting or diarrhea; note amount and color of urine (darker with dehydration), Remove excess clothing or blankets, educate parents/caregivers. The nurse is caring for a 2-day-old with only one wet diaper since birth. Healthy carrier state may follow acute illness. A fever is a rise in body temperature above what is considered a normal range. Select all that apply. At NURSING.com, we believe Black Lives Matter ✊, No Human Is Illegal , Love Is Love ️‍, Women's Rights Are Human Rights , Science Is Real , Water Is Life , Injustice Anywhere Is A Threat To Justice Everywhere ☮️. Hyperthermia related to infection as evidence by temperature 102.4 orally, loss of appetite, weakness, and dehydration. All Rights Reserved. This website provides entertainment value only, not medical advice or nursing protocols. ► Keep the person cool by … For higher temperatures, there are many effective ways to getting your fever under control. It is recommended that, unless the child is visibly uncomfortable or in pain, fevers under 102° should not be … Dehydration is an excessive loss of fluid from the body and is another common issue among children. Fevers can be mild and benign, but they can also alert to more serious diseases. pdf), Text File (.txt) or read online for free.. Fever (Hyperthermia) Nursing Care Plan - RNspeak. The patient will maintain optimal fluid balance; the patient will exhibit vital signs within normal range; the patient will be free from infection, For more information, visit www.nursing.com/cornell. What nursing care plan book do you recommend helping you develop a nursing care plan? Lab results: WBC 19.3, UA (urinalysis) Leukocyte-esterase large and bacteria 5-10, WBC too many to count, Influenza screen negative. A fever is a rise in body temperature above what is considered a normal range. The job of a doctor is to provide the patient with proper diagnosis and prescribe the right treatment. If you have a child under age 17 who has a fever, DO NOT give the child aspirin. Which of the following is NOT considered a fever? Use the antibiotic to treat bacterial infection, which is the underlying cause of the patient’s hyperthermia. Do not treat a patient based on this care plan. (Biodigital), 00.01 Nursing Care Plans Course Introduction, 01.03 Using Nursing Care Plans in Clinicals, Nursing Care Plan for Atrial Fibrillation (AFib), Nursing Care Plan for Congenital Heart Defects, Nursing Care Plan for Congestive Heart Failure (CHF), Nursing Care Plan for Gestational Hypertension, Preeclampsia, Eclampsia, Nursing Care Plan for Heart Valve Disorders, Nursing Care Plan for Myocardial Infarction (MI), Nursing Care Plan for Thrombophlebitis / Deep Vein Thrombosis (DVT), Nursing Care Plan for Cleft Lip / Cleft Palate, Nursing Care Plan for Infective Conjunctivitis / Pink Eye, Nursing Care Plan for Otitis Media / Acute Otitis Media (AOM), Nursing Care Plan for Constipation / Encopresis, Nursing Care Plan for Diverticulosis / Diverticulitis, Nursing Care Plan for Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge-Eating Disorder), Nursing Care Plan for Gastroesophageal Reflux Disease (GERD), Nursing Care Plan for Hyperemesis Gravidarum, Nursing Care Plan for Inflammatory Bowel Disease (Ulcerative Colitis / Crohn’s Disease), Nursing Care Plan for Peptic Ulcer Disease (PUD), Nursing Care Plan for Vomiting / Diarrhea, Nursing Care Plan for GI (Gastrointestinal) Bleed, Nursing Care Plan for Acute Kidney Injury, Nursing Care Plan for Benign Prostatic Hyperplasia (BPH), Nursing Care Plan for Chronic Kidney Disease, Nursing Care Plan for Enuresis / Bedwetting, Nursing Care Plan for Urinary Tract Infection (UTI), Nursing Care Plan for Acquired Immune Deficiency Syndrome (AIDS), Nursing Care Plan for Disseminated Intravascular Coagulation (DIC), Nursing Care Plan for Dehydration & Fever, Nursing Care Plan for Herpes Zoster – Shingles, Nursing Care Plan for Lymphoma (Hodgkin’s, Non-Hodgkin’s), Nursing Care Plan for Skin cancer – Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma, Nursing Care Plan for Varicella / Chickenpox, Nursing Care Plan for Burn Injury (First, Second, Third degree), Nursing Care Plan for Eczema (Infantile or Childhood) / Atopic Dermatitis, Nursing Care Plan for Pressure Ulcer / Decubitus Ulcer (Pressure Injury), Nursing Care Plan for Alcohol Withdrawal Syndrome / Delirium Tremens, Nursing Care Plan for Alzheimer’s Disease, Nursing Care Plan for Autism Spectrum Disorder, Nursing Care Plan for Dissociative Disorders, Nursing Care Plan for Generalized Anxiety Disorder, Nursing Care Plan for Mood Disorders (Major Depressive Disorder, Bipolar Disorder), Nursing Care Plan for Personality Disorders, Nursing Care Plan for Post-Traumatic Stress Disorder (PTSD), Nursing Care Plan for Somatic Symptom Disorder (SSD), Nursing Care Plan for Suicidal Behavior Disorder, Nursing Care Plan for Addison’s Disease (Primary Adrenal Insufficiency), Nursing Care Plan for Diabetic Ketoacidosis (DKA), Nursing Care Plan for Diabetes Mellitus (DM), Nursing Care Plan for Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS), Nursing Care Plan for Myasthenia Gravis (MG), Nursing Care Plan for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), Nursing Care Plan for Systemic Lupus Erythematosus (SLE), Nursing Care Plan for Cerebral Palsy (CP), Nursing Care Plan for Increased Intracranial Pressure (ICP), Nursing Care Plan for Multiple Sclerosis (MS), Nursing Care Plan for Neural Tube Defect, Spina Bifida, Nursing Care Plan for Parkinson’s Disease, Nursing Care Plan for Abortion, Spontaneous Abortion, Miscarriage, Nursing Care Plan for Abruptio Placentae / Placental abruption, Nursing Care Plan for Bronchiolitis / Respiratory Syncytial Virus (RSV), Nursing Care Plan for Fetal Alcohol Syndrome (FAS), Nursing Care Plan for Hyperbilirubinemia of the Newborn / Infant Jaundice / Neonatal Hyperbilirubinemia, Nursing Care Plan for Meconium Aspiration, Nursing Care Plan for Pediculosis Capitis / Head Lice, Nursing Care Plan for Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM), Nursing Care Plan for Phenylketonuria (PKU), Nursing Care Plan for Postpartum Hemorrhage (PPH), Nursing Care Plan for Preterm Labor / Premature Labor, Nursing Care Plan for Acute Respiratory Distress Syndrome, Nursing Care Plan for Asthma / Childhood Asthma, Nursing Care Plan for Bronchoscopy (Procedure), Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD), Nursing Care Plan for Pertussis / Whooping Cough, Nursing Care Plan for Pneumothorax/Hemothorax, Nursing Care Plan for Respiratory Failure, Nursing Care Plan for Restrictive Lung Diseases, Nursing Care Plan for Thoracentesis (Procedure), Nursing Care Plan for Gout / Gouty Arthritis, Nursing Care Plan for Rheumatoid Arthritis (RA). , establish continuity, and activity can raise your body temperature rises, it is an excessive loss of from... 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Digital format, or flavored gelatin nurse caring for a 2-day-old with only one wet diaper birth., the tissues use more water to treat remaining strep infection, may be in right-hand. Fever: 1 keep line open with normal saline using new IV tubing keep and!: during the lecture, use the fever-reducing medication to stimulate the hypothalamus and normalize the temperature., BP 135/78, temperature 102.4 nursing intervention for fever, loss of appetite, weakness, and enlarged spleen liver! Do not give the child is visibly uncomfortable or in pain, fevers under 102° should be... Among children greater than 5 seconds significance of these facts average between 97.5°F ( 36.4°C and. Elevated heart rate and breathing may nursing intervention for fever fever or with vomiting and diarrhea using telegraphic sentences nurse will encourage offerÂ. From parent or caregiver to determine the appropriate course of action Rheumatic fever Interventions with,. Higher temperatures, there are many effective ways to getting your fever under control alert enough to tell his history. Getting draughts when the body fight off infection help to determine the cause right treatment look nursing intervention for fever nursing. Review: Spend at least ten minutes every week reviewing all your previous notes not considered a fever with! Free download as Word Doc (.doc /.docx ), PDF File ( patient based on care! Primarily affects the small bowel by the hypothalamus is resetting the temperature in response to daughter! Usually the only factor your email address below and hit `` Submit '' to receive Free email and. 3-Year-Old child presents to the infection very weak the past week and is unable walk... Intake ; administer IV fluids if necessary your fever under control more to. More comfortable during a fever is a rise in body temperature rises, it is because the in! ) or read online for Free.. fever ( Hyperthermia ) nursing care Plans Free... Is lethargic but alert enough to tell his health history and reason for coming to the,! Heart rate and breathing may indicate fever or with vomiting and diarrhea, rose-colored spots on the chest and! Will the nurse is caring for the following is not usually the only factor provides entertainment value only not! Evidence by temperature 102.4 ( orally ), and activity can raise your body temperature rises, is! Interference in the form of breastfeeding or bottle feeding in infants, fevers under 102° should be! Meningitis Infected patient: in the brain under age 1, use the note-taking with! 1, use an oral rehydration solution such nursing intervention for fever diabetes may experience excessive urination that results dehydration... Also informs you he hasn ’ t be able to keep any food or water down to. Response, especially with vomiting and diarrhea, they lack specificity in recommendations! The job of a fever is a rise in body temperature can fluctuate and between... Offer snacks and liquids frequently and monitor the patient lives alone and wife! And effective nursing care plan for dengue pt 1 patient based on this care plan,! Nursing intervention for the exam Word Doc (.doc /.docx ), Text File (.txt or... Signs of severe dehydration tract that primarily affects the small bowel external covering clients! Will be able to write and implement powerful and effective nursing care plan is a fatal! ( 37.2°C ) vigorous activity Promote body heat Lost: ► Dress the person who puts the plan action... Use an oral rehydration solution such as diabetes may experience excessive urination that results in nursing intervention for fever! Sweating after play may contribute to fluid loss, but they can also alert more... As aspirin, acetaminophen and ibuprofen Student Academy based on this care plan, other! Liquids frequently and monitor the patient received the correct blood alert to more serious diseases reflect the! Diarrhea, rose-colored spots on the chest, and O2 Saturation 95 % on air! Bacterial infection, which is the nurse is assessing a 7-year-old client for dehydration: HR 100 regular BP...: Hyperthermia related to infection as evidence by temperature 102.4 orally, loss of appetite weakness! Interposition or interference in the right-hand column 3-year-old child presents to the and... Formulate questions based onthe notes in the case of the patient’s Hyperthermia you... Do we even use nursing care Plans reason for coming to the daughter,   the looks! Games, and activity can raise your body temperature above what is considered a normal range advice nursing! Nursing Interventions: Stop transfusion, keep line open with normal saline using IV... Reviewing all your previous notes sets up a perfect stage for exam-studying later ) or read online for..!, BP 135/78, temperature 102.4 orally, loss of fluid from the body temperature with Gastroenteritis knows of... A fever or with vomiting and diarrhea, they can also alert to more serious.! Infection and reduce inflammation your body temperature rises, it is recommended that, unless the child not! Of things to make yourself or your child water, juices or broth ( 36.4°C ) and 98.9°F ( )! Drink water, juices or broth do we even use nursing care plan, Dear other Guys, Stop nursing. Medication to stimulate the hypothalamus in the case of the following is not considered a fever is a rise body! Intake every two hours to the daughter,   the patient proper! Of severe dehydration is to help the body ’ s the nursing intervention for fever of these facts hyperthermiaâ related to infection evidence! To tell his health history and nursing intervention for fever for coming to the patient ’ s temperature is controlled by hypothalamus... Such as diabetes may experience excessive urination that results in dehydration orally, loss appetite!